Chapter Three - Patient and Doctor Expectations

This is the third chapter in my new book Health Reform in Perspective.

Prologue: This chapter addresses how a grateful elderly patient restored to full function by multiple surgeries assesses the system , how a prominent national medical politician foresees what patients should come to expect from an ideal health system, and how little effect government has on patient behavior .


“I Feel Like A Million Dollars,” The Case of an 80 Year Driver Restored to Full Function after Multiple Surgical Procedures

Recently , because of a broken Tie-rod which rendered my car’s steering inoperable, I paid a driver to take me to a doctor’s appointment.

During the ride, the driver confided to me he was 80 years old. I asked about his health. He replied,” I used to be totally disabled. I couldn’t walk. But thanks to a spinal fusion, two hip replacements, two knee replacements, two cataracts, and a heart pacemaker, I feel like a million dollars. Now I can work, I can see, I can drive, and I can even run.”

Give the matter any thought at all, and you will realize.

• The driver’s experience is what differentiates the U.S. from other nations who ration these procedures. In the process, they may wait months to years to have a procedure done, if at all.

• Why seniors are so leery about Health reform, which calls for $575 billion cuts in Medicare over the next ten years, and why remarks of Doctor Donald Berwick, Obama’s designate as head of CMS is so provocative to critics, “The decision is not whether or not we will ration care -- the decision is whether we will ration with our eyes open.”

Only time, the ten years it will take to roll out Medicare reform, will tell if this skepticism is justified.

In the meantime, we can ask these questions: Why is U.S. health care so expensive? Is it worth it? One reason is that U.S. citizens, no matter what their age, have quick access to high tech procedures that restore them to normal or near normal function. What is the price of increased worker productivity? What is the price of a pain-free existence?

Our driver, disabled and unable to walk, was restored to employment, to feeling well, and to being able to run.

It is useful to consider the cost of these various procedures, among the commonly performed in the U.S.

• Hip and knee replacements, about 1 million of these will be done this year in the U.S., at the cost of about $50,000 each. This amounts to $50 billion to the U.S., and $200,000 for the driver, who had four replacements.

• Spinal fusion, about 150,000 patients will undergo this most common spinal operation. At $70,000 per fusion, this will cost the U.S roughly $3.5 billion.

• Cataracts, 3 million per year, at a cost of about $4000 each.
This totals about $12 billion, and $8000 for our driver.

• Heart pacemaker and heart support implants, 100,000 per year, at a cost of about $100,000 each (pacemaker costs + operative + inpatient costs). $10 billion to U.S. and about $400,000 for the driver.

These costs are approximations. They are averages. They will vary with the complexity and nature of the illness and the various procedures. Nevertheless, they represent huge expenditures, $75 billion to the U.S. and $400, 000 for the driver. If one factors in such additional expenses as drugs, lab tests, and imaging (CTs, MRIs), the costs are undoubtedly much greater, perhaps even double, maybe close to $1 million for our driver.

Are these expenditures worth it? They are to the driver, who feels like a million dollars. And they are to the 47 million Medicare recipients who expect these procedures to be done when they need them.

How can the government reduce these costs?

• One, by overt or covert rationing.

• Two, by reducing fees for physicians , hospitals, and rehabilitation facilities.

These will not be easy decisions for the Obama administration to make. The fact that indications for these procedures – pain, disability, immobility, and heart failure – are usually clear cut makes decision-making even more difficult.

The case of driver who, thanks to effective medical care that made him fully-functional, puts the matter in perspective.

The Ideal Health System - Summary of Interview with Donald Palmisano, MD, former AMA President and Founder of Intrepid Resource®

Preface: Donald Palmisano, MD, JD, is perhaps organized medicine’s most articulate spokesman, and one of the few who equally grasps medicine and legal issues He served as president of the American Medical Association in 2003-2004. Dr. Palmisano speaks often on malpractice’s hidden costs. He is Founder and President of Intrepid Resources ®, a risk management and patient safety company.

Q: Doctor Palmisano, have we reached a watershed moment in American health care?

A: Yes, we have reached a critical moment, Government and third party intervention is disconnecting the patient from the physician and the decision making from the patient’s best interest. The ideal system is one where patients own their health insurance and makes decisions with the doctor as trusted advisor.

Q: What system do we have now?

A: We have third parties saying what treatment will be allowed. We have government taking away the right of private contracting between patients and physicians. With Medicare, doctors must accept what government pays because if you do a private contract the physician is removed from Medicare for two years. We are moving towards more government control, a system that will not lower costs, and one in which physicians are being paid less than the cost of delivering care.

Because a patient has a Medicare or Medicaid card does not mean that patient will find a physician in his or her hour of need. Fewer and fewer doctors accept Medicare or Medicaid patients because federal and state government pays less than the cost of delivering care. Price fixing has never worked, and it is not going to work in medicine.

I recommend expanding coverage through tax credits, consumer choice, market enhancement, low cost health savings accounts, individual ownership of insurance, extending subsidies to those who need financial help, the right to privately contract between patients and doctors, and purchasing insurance across state lines.

These free market principles would take care of the monopsony power of health insurers, what they allow patients to receive, and what they pay the doctor.

Q: Can independent doctors in small practices do anything to change the dynamics?

A: Independent physicians represent 80% of practices. They have to be engaged in the political process by contacting their representatives in Congress and their two Senators and telling them how adversely this interference is effecting their practice. They should encourage their patients to do the same.

Otherwise folks in Washington will remain in their bubble. They don’t hear enough about what’s happening in the actual practice of medicine. They are just listening to talking heads and think tank wonks.

The public is being given bad information. When the President of the United States says a physician would amputate a leg to get $50,000 rather than treating the patient medically, he is getting bad information from advisors. When he says a doctor will do a tonsillectomy rather than treating a child for tonsillitis, it is not appropriate. We need to get the real fact and to identify what the problems are.

First, some health insurers ignore patients and physicians Their misplaced monopsony power allows them to dictate terms. We fix that by competition across state lines.

Second, we need to get insurance for people with pre-existing conditions. We can do that with voluntary purchasing cooperatives so people can get together in groups of 10,000 or more. Everybody can be accepted when they have the options of getting bids on large groups, just as in a large company like IBM.

Third, why should people on Medicaid have less than ideal access to care? Convert Medicaid into a defined contribution. Give them the same advantages as people in the Federal Employee Health Benefits (FEHB) Program. Give them a voucher, and allow them to choose from an array of choices.

Government should not assume the American public is not smart enough to make their own decisions. We need more control given to patients, the same tax advantages for every American.

With this government plan, we will end up with Medicaid-for-all, with long waiting lines, and no doctors to treat them. Physicians will do something else. They will limit their practice, or switch to concierge or cash practices and directly contract with patients.

They will get out of Medicare, Medicaid, and all insurance programs. That’s not good for anybody.
Diabetes, Obesity, and Government
Obesity and its stepchild, type 2 diabetes, have replaced smoking as the leading health hazards. Yet despite government and public health pleadings to eat less, move more, lose weight, the obesity and diabetes epidemics are on a tear.

Here is how the WSJ Health Blog assesses the situation:

“Editors of the Lancet didn’t mince words when they weighed in on the epidemic of type 2 diabetes — they said the fact that the mostly preventable disease has become so prevalent is ‘a public health humiliation.’ ”

“Medicine might be winning the battle of glucose control, but it is losing the war against diabetes,” the authors write."

“ ‘Lifestyle interventions’ is another name for efforts to convince people to lose or maintain weight, eat a more healthful diet and get more physical activity. When people do make changes, good things can happen - even a 7% weight loss can produce much as a 58% improvement in the risk of progressing from pre-diabetes to diabetes.”

“It’s not like the diet and exercise message hasn’t been broadcast loud and clear, especially in the U.S. and other western countries, but public-health entreaties don’t always work. Most adults aren’t supposed to eat more than a teaspoon of salt per day, for example, but a CDC study released yesterday says only 10% of us do that. And other CDC statistics released recently show that in 2009, 29% of Americans were obese. “

Hapless Government

Why is government so hapless in persuading people to change for their own good?

I suspect the answer lies in complexity of human society and its desire for personal freedom.

In his classic The Road to Serfdom (1944), conservative economist Friedrich Hayek wrote that the economy and society are too complicated for centralized government to control and intervene at marketplace or lifestyle levels. That is why the economic stimulus package of February 2009 has failed to raise employment and why the health bill is unlikely to change patients’ lifestyles.

Hayek contended political freedom and economic freedom are inextricably linked. In a centrally planned economy, the state infringes on what we do, what we enjoy, and where we live. When the state has the final say on the economy, we need permission of the state to act, speak and write. Economic control becomes political control.

The problem with political control is that it attracts people who relish running the lives of others. Further, powerful politicians take care of their friends first and the people second.

Americans are suffering from top-down overkill. President Obama has expanded federal control of health care. By doing so, he has left fewer resources for the rest of us to direct through our own decisions. In a free modern society, we cooperate with others to produce the goods and services we enjoy, all without top-down direction.

This holds true in everything that makes life worthwhile —when we sing and when we dance, when we play and when we pray. Leaving us free to join with others as we see fit—in our work and in our play—is the road to true and lasting prosperity.

Sources:

Katherine Hobson, “ ‘Type 2 Diabetes Epidemic Called a ‘Public Health Humiliation’” Wall Street Journal Health Blog,, June 25, 2010.